Medication Administration: Pharmacyâ€™s New Frontier?
by Scott A. Meyers, Executive Vice President
August 1, 2009
Having worked in health care for more than 20 years before fully and completely stepping into this role of Executive Director and now Executive Vice President of ICHP, I thought I was tuned into the health care experience from both a practitioner and patient point of view. I was sure that our health-systems were doing the best that they could to provide safe and effective care and that the areas of responsibility for pharmacy and pharmacists were fairly appropriate at that time. Then came the Joint Commission’s push for pharmacy oversight of all medications throughout the health care institution and medication reconciliation, both of which made good sense.
Now I wonder if the next frontier should be pharmacy/pharmacist oversight of the medication administration process. Let me share why I raise this point. At the end of June, my wife Lana received a total knee replacement. I know hospitals have been doing total knees, total hips, valve replacements, and many other prosthetic surgeries even before my separation from direct patient care. However, I never really thought about them the same way I did when it was a family member on the table or in the bed this time. In preparation for the surgery, the orthopedic surgeon spent several minutes with my wife and me describing the procedure, the pre- and post-op care she would receive and the recovery process. The one detail that caught my attention was what would happen if a post-op infection occurred. The physician would be forced to bring my wife back to surgery, remove the prosthesis, replace it with a cement plug and then she would need to undergo several weeks if not months of antibiotic therapy before the artificial knee could be replaced.
Because his words touched a nerve, I was really tuned into the post-op antibiotics she received. Now the care she received at the institution was outstanding! Let me say that up front to be perfectly clear. She raved about the way the nurses and nurses’ aides treated her and how everyone was so friendly and encouraging. I think eventually she will praise the physical therapists, too, but the memory of their helpful torture is still fresh in her mind!
I did my best to be her medication advocate once she arrived on the nursing unit where she would spend her three inpatient days before going home to the loving care of her poorly trained and ill-equipped husband. Her surgery was to begin at 10:30 a.m. but as most surgeries go, started at 11:00 a.m. or later. I knew that the cefazolin was hanging and ready to be connected as she was set up in the surgical suite, so step one was good to go. However, that evening at around 7:30 p.m. I started to get nervous. Was that still the pre-op dose hanging? It was empty, and I cursed myself for not memorizing the label beforehand to insure better control on my part! What was the order for post-op antibiotics? How often? What dose? I assumed it would be cefazolin again but could I be sure? Sometimes a little knowledge is a bad thing! At 7:45 p.m. I went to the nursing desk to ask when the next dose was due. A seemingly uninterested nurse replied that she would check on it and let me know. I returned to the room and waited. Fortunately, my wife’s nurse arrived within 5-10 minutes with dose in hand, and we were back to full strength coverage! It was cefazolin, this time 1 gram (the previous dose was 2 grams), and it began to run fine.
That’s when it hit me! These antibiotics were crucial to my wife’s successful recovery, and timing is critically important with each dose (or at least when it’s my family member they are). But she also takes other chronic meds that if left un-administered, could cause serious other problems that nurses on an orthopedic unit might not understand or be prepared to manage. The scary thing is that the medications my wife takes are taken by a significant portion of the population of the US! Did the nurses understand the importance of staying on schedule and not missing a dose? Did their training impart the importance of timing and dosage? My years of experience in the trenches (or should I say basement) of institutions like this one conjured up memories of calls for missing meds hours after they were supposed to be given, missed charting of doses given and charting of doses that couldn’t have been given because the meds were returned or never sent.
Pharmacists know the importance that timing and the patient’s condition play in the effectiveness of the medications ordered. Pharmacists are trained to spot problems in therapy as the patient’s conditions change. However, pharmacists are often too disconnected from the patient to apply what they know to assure or improve outcomes.
But should pharmacists spend their days in the future strictly on administering medications? I don’t think that would be effective use of a highly trained resource. How can my concerns be dealt with while utilizing pharmacists effectively?
ICHP has joined with ASHP and many other of its state affiliates in their “Pharmacy Technician Initiative”. This initiative calls upon each state to attain three important goals with regard to pharmacy technician regulation. In Illinois, two of the three goals have been accomplished: the requirement that all technicians become certified and that all technicians are registered by the State of Illinois. Illinois has had registration in place for decades, and now all new technicians (those initially registered after Jan. 1, 2008) must become certified before their second registration renewal. The first goal of the three, all pharmacy technicians will complete an accredited training program, is still far from a reality. ICHP is working with community colleges and hospital based training programs to encourage them to attain accreditation from ASHP (the only current accrediting body). We are encouraging pharmacy directors to move to this requirement once programs exist in their area. Hopefully, once this final goal is accomplished, pharmacy will be positioned to provide comprehensive and safe pharmacist care to patients in every practice setting.
Accomplishment of the ASHP Pharmacy Technician Initiative coupled with the implementation of more and more readily available technology and automation will make the concept of pharmacy managed medication administration a much more feasible goal. Don’t get me wrong; I know pharmacy managed medication administration isn’t a new concept! It goes on in several parts of the country and with varying success today and even in the past. But how can we as a profession seriously consider providing this type of patient care without a highly-trained and well supervised core of pharmacy technicians? Eventually, if this occurs, I see these well trained med administration technicians teaching our students how to administer medications to their patients. I see pharmacy graduates and practitioners who are even more focused on not only what medication is being used on their patients but how that medication is working and what can be done to further improve the patient outcomes. By getting involved with the medication administration process, our direct contact with the patients (by both technicians and pharmacists) can have dramatic affects on health care outcomes and experiences.
Maybe medication administration won’t be the next frontier, and I’m sure if pharmacy became involved it wouldn’t be the final frontier either. But it certainly could be a frontier that could change our practice and profession forever!
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